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Healthcare-associated infections: prevention and control in primary and community care
Clinical guideline
Published: 28 March 2012 www.nice.org.uk/guidance/cg139
© NICE 2021. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-of-rights). Last updated 15 February 2017
Your responsibility Your responsibility The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual needs,
preferences and values of their patients or the people using their service. It is not mandatory to
apply the recommendations, and the guideline does not override the responsibility to make
decisions appropriate to the circumstances of the individual, in consultation with them and their
families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be
applied when individual professionals and people using services wish to use it. They should do so in
the context of local and national priorities for funding and developing services, and in light of their
duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a
way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable
health and care system and should assess and reduce the environmental impact of implementing
NICE recommendations wherever possible.
Healthcare-associated infections: prevention and control in primary and community care (CG139)
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Contents Contents Overview ............................................................................................................................................................................ 4
Who is it for? .................................................................................................................................................................................. 4
Introduction ...................................................................................................................................................................... 5
Clinical context ............................................................................................................................................................................. 5
Rationale for the update ........................................................................................................................................................... 6
Audience .......................................................................................................................................................................................... 6
Medical Device Regulations .................................................................................................................................................... 7
Use of 'must' in recommendations ........................................................................................................................................ 7
Drug recommendations ............................................................................................................................................................. 7
Patient-centred care ...................................................................................................................................................... 9
Key priorities for implementation ............................................................................................................................ 10
1 Guidance ......................................................................................................................................................................... 14
Terms used in this guidance ..................................................................................................................................................... 14
1.1 Standard principles ............................................................................................................................................................. 14
1.2 Long-term urinary catheters ............................................................................................................................................ 19
1.3 Enteral feeding ....................................................................................................................................................................... 23
1.4 Vascular access devices ...................................................................................................................................................... 24
2 Research recommendations ................................................................................................................................... 30
2.1 Standard principles of infection prevention and control ...................................................................................... 30
2.2 Hand decontamination ....................................................................................................................................................... 30
2.3 Intermittent urinary catheters: catheter selection ................................................................................................. 31
2.4 Indwelling urinary catheters: catheter selection ..................................................................................................... 32
2.5 Indwelling urinary catheters: antibiotic prophylaxis ............................................................................................. 32
2.6 Vascular access devices: skin decontamination ....................................................................................................... 33
More information ......................................................................................................................................................................... 33
Update information ........................................................................................................................................................ 34
Healthcare-associated infections: prevention and control in primary and community care (CG139)
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This guideline replaces CG2.
This guideline is the basis of QS61.
Overview Overview This guideline covers preventing and controlling healthcare-associated infections in children,
young people and adults in primary and community care settings. It provides a blueprint for the
infection prevention and control precautions that should be applied by everyone involved in
delivering NHS care and treatment.
Who is it for? Who is it for?
• Commissioners and providers
• Healthcare professionals working in primary and community care settings, including
ambulance services, schools and prisons
• Children, young people and adults receiving healthcare for which standard infection-control
precautions apply in primary and community care, and their families and carers
Healthcare-associated infections: prevention and control in primary and community care (CG139)
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Introduction Introduction
This guideline partially updates and replaces 'Infection control: prevention of healthcare-
associated infection in primary and community care' (NICE clinical guideline 2). The
recommendations are labelled according to when they were originally published (see About this
guideline for details).
Clinical context Clinical context
A wide variety of healthcare is delivered in primary and community care settings. Healthcare-
associated infections arise across a wide range of clinical conditions and can affect patients of all
ages. Healthcare workers, family members and carers are also at risk of acquiring infections when
caring for patients.
Healthcare-associated infections can occur in otherwise healthy individuals, especially if invasive
procedures or devices are used. For example, indwelling urinary catheters are the most common
cause of urinary tract infections, and bloodstream infections are associated with vascular access
devices.
Healthcare-associated infections are caused by a wide range of microorganisms. These are often
carried by the patients themselves, and have taken advantage of a route into the body provided by
an invasive device or procedure. Healthcare-associated infections can exacerbate existing or
underlying conditions, delay recovery and adversely affect quality of life.
Patient safety has become a cornerstone of care, and preventing healthcare-associated infections
remains a priority. It is estimated that 300,000 patients a year in England acquire a healthcare-
associated infection as a result of care within the NHS. In 2007, meticillin-resistant Staphylococcus
aureus (MRSA) bloodstream infections and Clostridium difficile infections were recorded as the
underlying cause of, or a contributory factor in, approximately 9000 deaths in hospital and primary
care in England.
Healthcare-associated infections are estimated to cost the NHS approximately £1 billion a year,
and £56 million of this is estimated to be incurred after patients are discharged from hospital. In
addition to increased costs, each one of these infections means additional use of NHS resources,
greater patient discomfort and a decrease in patient safety. A no-tolerance attitude is now
prevalent in relation to avoidable healthcare-associated infections.
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Rationale for the update Rationale for the update
Since the publication of the NICE clinical guideline on the prevention of healthcare-associated
infection in primary and community care in 2003, many changes have occurred within the NHS that
place the patient firmly at the centre of all activities. First, the NHS Constitution for England
defines the rights and pledges that every patient can expect regarding their care. To support this,
the Care Quality Commission (CQC), the independent regulator of all health and adult social care in
England, ensures that health and social care is safe, and monitors how providers comply with
established standards. In addition, the legal framework that underpins the guidance has changed
since 2003.
New guidance is needed to reflect the fact that, as a result of the rapid turnover of patients in acute
care settings, complex care is increasingly being delivered in the community. New standards for the
care of patients and the management of devices to prevent related healthcare-associated
infections are needed that will also reinforce the principles of asepsis.
This guideline assumes that all providers of healthcare in primary and community care settings are
compliant with current code of practice on preventing and controlling infections[1]. The guideline
aims to help build on advice given in the code and elsewhere to improve the quality of care and
practice in these areas over and above current standards.
The Guideline Development Group (GDG) recognises the important contribution that surveillance
makes to monitoring infection, but it is not within the scope of this guideline to make specific
recommendations about this subject.
This clinical guideline is a partial update of 'Infection control: prevention of healthcare-associated
infection in primary and community care' (NICE clinical guideline 2; 2003), and addresses areas in
which clinical practice for preventing healthcare-associated infections in primary and community
care has changed, where the risk of healthcare-associated infections is greatest or where the
evidence has changed. Where high-quality evidence is lacking, the GDG has highlighted areas for
further research.
Audience Audience
The population covered in this guideline is all adults and children receiving healthcare for which
standard infection-control precautions apply in primary care and community care. This guideline is
commissioned by the NHS, but people providing healthcare in other settings, such as private
settings, may also find the guidance relevant.
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This guideline applies to all healthcare workers employed in primary and community care settings,
including ambulance services, and should ensure safe practice if applied consistently. Much care is
also delivered by informal carers and family members, and this guideline is equally applicable to
them.
Healthcare settings covered by this guideline are:
• Primary care settings, such as general practices, dental clinics, health centres and polyclinics.
This also includes care delivered by the ambulance service.
• Community care settings, such as residential homes, nursing homes, the patient's own home,
schools and prisons, where NHS healthcare is provided or commissioned.
Medical Device Regulations Medical Device Regulations
The Medical Device Regulations implement the EC Medical Devices Directives into UK law. They
place obligations on manufacturers to ensure that their devices (including medical gloves, needles
and other devices discussed in this guideline) are safe and fit for their intended purpose before they
are CE marked and placed on the market in any EC member state. Guidance on the MHRA's adverse
incident reporting system is available for reporting adverse incidents involving medical devices.
Use of 'must' in recommendations Use of 'must' in recommendations
The GDG recognised that there is a legal duty to implement some of the recommendations in this
guideline in order to comply with legislation. The word 'must' is used in these recommendations
and details of the relevant legislation are given in footnotes to the recommendations.
The GDG was also aware that the consequences of not implementing some other
recommendations on patient safety would be very serious – that is, there would be a greatly
increased risk of adverse events, including death. The GDG therefore concluded that the use of the
word 'must' in these recommendations is justified, in line with the guidance in chapter 9 of 'The
guidelines manual (2009)'.
Drug recommendations Drug recommendations
The guideline will assume that prescribers will use a drug's summary of product characteristics to
inform decisions made with individual patients.
This guideline recommends some drugs for indications for which they do not have a UK marketing
Healthcare-associated infections: prevention and control in primary and community care (CG139)
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authorisation at the date of publication, if there is good evidence to support that use. Where
recommendations have been made for the use of drugs outside their licensed indications ('off label
use'), these drugs are marked with a footnote in the recommendations.
[1] At the time of publication of the guideline (March 2012): The Health and Social Care Act 2008
Code of Practice on the prevention and control of infections and related guidance.
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Patient-centred care Patient-centred care This guideline offers best practice advice on the prevention and control of healthcare-associated
infections in primary and community care.
Patients have the right to expect that those who provide their care meet appropriate standards of
hygiene and follow the correct procedures to minimise the risk of healthcare-associated infection.
Treatment and care should also take into account patients' needs and preferences. Patients should
have the opportunity to make informed decisions about their care and treatment, in partnership
with their healthcare professionals. If patients do not have the capacity to make decisions,
healthcare professionals should follow the Department of Health's advice on consent and the code
of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should
follow advice on consent from the Welsh Government.
If the patient is under 16, healthcare professionals should follow the guidelines in the Department
of Health's Seeking consent: working with children.
Good communication between healthcare professionals and patients is essential. It should be
supported by evidence-based written information tailored to the patient's needs. Treatment and
care, and the information patients are given about it, should be culturally appropriate. It should also
be accessible to people with additional needs such as physical, sensory or learning disabilities, and
to people who do not speak or read English.
If the patient agrees, families and carers should have the opportunity to be involved in decisions
about treatment and care.
Families and carers should also be given the information and support they need.
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Key priorities for implementation Key priorities for implementation The following recommendations have been identified as priorities for implementation.
Standard principles: general advice Standard principles: general advice
• Everyone involved in providing care should be:
- educated about the standard principles of infection prevention and control and and
- trained in hand decontamination, the use of personal protective equipment, and the safe
use and disposal of sharps. [2012] [2012]
• Wherever care is delivered, healthcare workers must[2] have available appropriate supplies of:
- materials for hand decontamination
- sharps containers
- personal protective equipment. [new 2012] [new 2012]
• Educate patients and carers about:
- the benefits of effective hand decontamination
- the correct techniques and timing of hand decontamination
- when it is appropriate to use liquid soap and water or handrub
- the availability of hand decontamination facilities
- their role in maintaining standards of healthcare workers' hand decontamination. [new [new
2012] 2012]
Standard principles for hand decontamination Standard principles for hand decontamination
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• Hands must be decontaminated in all of the following circumstances:
- immediately before every episode of direct patient contact or care, including aseptic
procedures
- immediately after every episode of direct patient contact or care
- immediately after any exposure to body fluids
- immediately after any other activity or contact with a patient's surroundings that could
potentially result in hands becoming contaminated
- immediately after removal of gloves. [new 2012] [new 2012]
Long-term urinary catheters Long-term urinary catheters
• Select the type and gauge of an indwelling urinary catheter based on an assessment of the
patient's individual characteristics, including:
- age
- any allergy or sensitivity to catheter materials
- gender
- history of symptomatic urinary tract infection
- patient preference and comfort
- previous catheter history
- reason for catheterisation. [new 2012] [new 2012]
• All catheterisations carried out by healthcare workers should be aseptic procedures. After
training, healthcare workers should be assessed for their competence to carry out these types
of procedures. [2003] [2003]
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• When changing catheters in patients with a long-term indwelling urinary catheter:
- do not offer antibiotic prophylaxis routinely
- consider antibiotic prophylaxis[3] for patients who:
◇ have a history of symptomatic urinary tract infection after catheter change or or
◇ experience trauma[4] during catheterisation. [new 2012] [new 2012]
Vascular access devices Vascular access devices
• Before discharge from hospital, patients and their carers should be taught any techniques they
may need to use to prevent infection and safely manage a vascular access device[5]. [2003, [2003,
amended 2012] amended 2012]
• Healthcare workers caring for a patient with a vascular access device[5] should be trained, and
assessed as competent, in using and consistently adhering to the infection prevention practices
described in this guideline. [2003, amended 2012] [2003, amended 2012]
• Decontaminate the skin at the insertion site with chlorhexidine gluconate[6] in 70% alcohol
before inserting a peripheral vascular access device or a peripherally inserted central catheter.
[new 2012] [new 2012]
[2] In accordance with current health and safety legislation (at the time of publication of the
guideline [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety
at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous
to Health Regulations 2002, Personal Protective Equipment Regulations 2002 and Health and
Social Care Act 2008.
[3] At the time of publication of the guideline (March 2012), no antibiotics have a UK marketing
authorisation for this indication. Informed consent should be obtained and documented.
[4] The GDG defined trauma as frank haematuria after catheterisation or two or more attempts of
catheterisation.
[5] The updated recommendation contains 'vascular access device' rather than 'central venous
catheter'. This change has been made because peripherally inserted catheters were included in the
scope of the guideline update.
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[6] In 2012 a safety alert for chlorhexidine was issued related to the risk of adverse events.
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1 1 Guidance Guidance The following guidance is based on the best available evidence. The full guideline gives details of
the methods and the evidence used to develop the guidance.
Terms used in this guidance Terms used in this guidance
Aseptic techniqueAseptic technique An aseptic technique ensures that only uncontaminated equipment and fluids
come into contact with susceptible body sites. It should be used during any clinical procedure that
bypasses the body's natural defences. Using the principles of asepsis minimises the spread of
organisms from one person to another.
Direct patient care Direct patient care 'Hands on' or face-to-face contact with patients. Any physical aspect of the
healthcare of a patient, including treatments, self-care and administration of medication.
Hand decontaminationHand decontamination The use of handrub or handwashing to reduce the number of bacteria on
the hands. In this guideline this term is interchangeable with 'hand hygiene'.
HandrubHandrub A preparation applied to the hands to reduce the number of viable microorganisms. This
guideline refers to handrubs compliant with British standards (BS EN1500; standard for efficacy of
hygienic handrubs using a reference of 60% isopropyl alcohol).
Healthcare workerHealthcare worker Any person employed by the health service, social services, a local authority or
an agency to provide care for a sick, disabled or elderly person.
Healthcare wasteHealthcare waste In this guideline, healthcare waste refers to any waste produced by, and as a
consequence of, healthcare activities.
Personal protective equipmentPersonal protective equipment Equipment that is intended to be worn or held by a person to
protect them from risks to their health and safety while at work. Examples include gloves, aprons,
and eye and face protection.
1.1 1.1 Standard principles Standard principles
1.1.1 1.1.1 General advice General advice
1.1.1.1 Everyone involved in providing care should be:
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• educated about the standard principles of infection prevention and control and and
• trained in hand decontamination, the use of personal protective equipment, and the
safe use and disposal of sharps. [2012] [2012]
1.1.1.2 Wherever care is delivered, healthcare workers must[7] have available
appropriate supplies of:
• materials for hand decontamination
• sharps containers
• personal protective equipment. [new 2012] [new 2012]
1.1.1.3 Educate patients and carers about:
• the benefits of effective hand decontamination
• the correct techniques and timing of hand decontamination
• when it is appropriate to use liquid soap and water or handrub
• the availability of hand decontamination facilities
• their role in maintaining standards of healthcare workers' hand decontamination. [new [new
2012] 2012]
1.1.2 1.1.2 Hand decontamination Hand decontamination
1.1.2.1 Hands must be decontaminated in all of the following circumstances:
• immediately before every episode of direct patient contact or care, including aseptic
procedures
• immediately after every episode of direct patient contact or care
• immediately after any exposure to body fluids
• immediately after any other activity or contact with a patient's surroundings that
could potentially result in hands becoming contaminated
• immediately after removal of gloves. [new 2012] [new 2012]
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1.1.2.2 Decontaminate hands preferably with a handrub (conforming to current British
standards[8]), except in the following circumstances, when liquid soap and water
must be used:
• when hands are visibly soiled or potentially contaminated with body fluids or or
• in clinical situations where there is potential for the spread of alcohol-resistant
organisms (such as Clostridium difficile or other organisms that cause diarrhoeal illness).
[new 2012] [new 2012]
1.1.2.3 Healthcare workers should ensure that their hands can be decontaminated
throughout the duration of clinical work by:
• being bare below the elbow[9] when delivering direct patient care
• removing wrist and hand jewellery
• making sure that fingernails are short, clean and free of nail polish
• covering cuts and abrasions with waterproof dressings. [new 2012] [new 2012]
1.1.2.4 An effective handwashing technique involves three stages: preparation,
washing and rinsing, and drying. Preparation requires wetting hands under tepid
running water beforebefore applying liquid soap or an antimicrobial preparation. The
handwash solution must come into contact with allall of the surfaces of the hand.
The hands must be rubbedrubbed together vigorously for a minimum of
10–15 seconds, paying particular attention to the tips of the fingers, the thumbs
and the areas between the fingers. Hands should be rinsed thoroughly before
drying with good quality paper towels. [2003] [2003]
1.1.2.5 When decontaminating hands using an alcohol handrub, hands should be free
from dirt and organic material. The handrub solution must come into contact
with all surfaces of the hand. The hands must be rubbedrubbed together vigorously,
paying particular attention to the tips of the fingers, the thumbs and the areas
between the fingers, until the solution has evaporated and the hands are dry.
[2003] [2003]
1.1.2.6 An emollient hand cream should be applied regularly to protect skin from the
drying effects of regular hand decontamination. If a particular soap,
antimicrobial hand wash or alcohol product causes skin irritation an
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occupational health team should be consulted. [2003] [2003]
1.1.3 1.1.3 Use of personal protective equipment Use of personal protective equipment
1.1.3.1 Selection of protective equipment must[7] be based on an assessment of the risk
of transmission of microorganisms to the patient, and the risk of contamination
of the healthcare worker's clothing and skin by patients' blood, body fluids,
secretions or excretions. [2003] [2003]
1.1.3.2 Gloves used for direct patient care:
• must[7] conform to current EU legislation (CE marked as medical gloves for single
use)[10]and and
• should be appropriate for the task. [new 2012] [new 2012]
1.1.3.3 Gloves must[7] be worn for invasive procedures, contact with sterile sites and
non-intact skin or mucous membranes, and all activities that have been assessed
as carrying a risk of exposure to blood, body fluids, secretions or excretions, or
to sharp or contaminated instruments. [2003] [2003]
1.1.3.4 Gloves must[7] be worn as single-use items. They must be put on immediately
before an episode of patient contact or treatment and removed as soon as the
activity is completed. Gloves must be changed between caring for different
patients, and between different care or treatment activities for the same
patient. [2003] [2003]
1.1.3.5 Ensure that gloves used for direct patient care that have been exposed to body
fluids are disposed of correctly, in accordance with current national legislation[11]
or local policies (see section 1.1.5). [new 2012] [new 2012]
1.1.3.6 Alternatives to natural rubber latex gloves must[7] be available for patients,
carers and healthcare workers who have a documented sensitivity to natural
rubber latex. [2012] [2012]
1.1.3.7 Do not use polythene gloves for clinical interventions. [new 2012] [new 2012]
1.1.3.8 When delivering direct patient care:
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• wear a disposable plastic apron if there is a risk that clothing may be exposed to blood,
body fluids, secretions or excretions or or
• wear a long-sleeved fluid-repellent gown if there is a risk of extensive splashing of
blood, body fluids, secretions or excretions onto skin or clothing. [2012] [2012]
1.1.3.9 When using disposable plastic aprons or gowns:
• use them as single-use items, for one procedure or one episode of direct patient care
and and
• ensure they are disposed of correctly (see section 1.1.5). [2012] [2012]
1.1.3.10 Face masks and eye protection must[7] be worn where there is a risk of blood,
body fluids, secretions or excretions splashing into the face and eyes. [2003] [2003]
1.1.3.11 Respiratory protective equipment, for example a particulate filter mask, must[7]
be used when clinically indicated. [2003] [2003]
1.1.4 1.1.4 Safe use and disposal of sharps Safe use and disposal of sharps
1.1.4.1 Sharps should[12] not be passed directly from hand to hand, and handling should
be kept to a minimum. [2003, amended 2012] [2003, amended 2012]
1.1.4.2 Used standard needles:
• must not be bent[13] or broken before disposal
• must not be recapped.
In dentistry, if recapping or disassembly is unavoidable, a risk assessment must be
undertaken and appropriate safety devices should be used[14]. [new 2012] [new 2012]
1.1.4.3 Used sharps must be discarded immediately by the person generating the
sharps waste into a sharps container conforming to current standards[15]. [new [new
2012] 2012]
1.1.4.4 Sharps containers:
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• must[11] be located in a safe position that avoids spillage, is at a height that allows the
safe disposal of sharps, is away from public access areas and is out of the reach of
children
• must not[11] be used for any other purpose than the disposal of sharps
• must not[11] be filled above the fill line
• must[11] be disposed of when the fill line is reached
• should be temporarily closed when not in use
• should be disposed of every 3 months even if not full, by the licensed route in
accordance with local policy. [new 2012] [new 2012]
1.1.4.5 Use sharps safety devices if a risk assessment has indicated that they will
provide safer systems of working for healthcare workers, carers and patients.
[new 2012] [new 2012]
1.1.4.6 Train and assess all users in the correct use and disposal of sharps and sharps
safety devices. [new 2012] [new 2012]
1.1.5 1.1.5 Waste disposal Waste disposal
1.1.5.1 Healthcare waste must be segregated immediately by the person generating the
waste into appropriate colour-coded storage or waste disposal bags or
containers defined as being compliant with current national legislation[11] and
local policies. [new[new 2012] 2012]
1.1.5.2 Healthcare waste must be labelled, stored, transported and disposed of in
accordance with current national legislation[11] and local policies. [new 2012] [new 2012]
1.1.5.3 Educate patients and carers about the correct handling, storage and disposal of
healthcare waste. [new 2012] [new 2012]
1.2 1.2 Long-term urinary catheters Long-term urinary catheters
1.2.1 1.2.1 Education of patients, their carers and healthcare workers Education of patients, their carers and healthcare workers
1.2.1.1 Patients and carers should be educated about and trained in techniques of hand
decontamination, insertion of intermittent catheters where applicable, and
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catheter management before discharge from hospital. [2003] [2003]
1.2.1.2 Community and primary healthcare workers must be trained in catheter
insertion, including suprapubic catheter replacement and catheter
maintenance. [2003] [2003]
1.2.1.3 Follow-up training and ongoing support of patients and carers should be
available for the duration of long-term catheterisation. [2003] [2003]
1.2.2 1.2.2 Assessing the need for catheterisation Assessing the need for catheterisation
1.2.2.1 Indwelling urinary catheters should be used only after alternative methods of
management have been considered. [2003] [2003]
1.2.2.2 The patient's clinical need for catheterisation should be reviewed regularly and
the urinary catheter removed as soon as possible. [2003] [2003]
1.2.2.3 Catheter insertion, changes and care should be documented. [2003] [2003]
1.2.3 1.2.3 Catheter drainage options Catheter drainage options
1.2.3.1 Following assessment, the best approach to catheterisation that takes account
of clinical need, anticipated duration of catheterisation, patient preference and
risk of infection should be selected. [2003] [2003]
1.2.3.2 Intermittent catheterisation should be used in preference to an indwelling
catheter if it is clinically appropriate and a practical option for the patient.
[2003] [2003]
1.2.3.3 Offer a choice of either single-use hydrophilic or gel reservoir catheters for
intermittent self-catheterisation. [new 2012] [new 2012]
1.2.3.4 Select the type and gauge of an indwelling urinary catheter based on an
assessment of the patient's individual characteristics, including:
• age
• any allergy or sensitivity to catheter materials
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• gender
• history of symptomatic urinary tract infection
• patient preference and comfort
• previous catheter history
• reason for catheterisation. [new 2012] [new 2012]
1.2.3.5 In general, the catheter balloon should be inflated with 10 ml of sterile water in
adults and 3–5 ml in children. [2003] [2003]
1.2.3.6 In patients for whom it is appropriate, a catheter valve may be used as an
alternative to a drainage bag. [2003] [2003]
1.2.4 1.2.4 Catheter insertion Catheter insertion
1.2.4.1 All catheterisations carried out by healthcare workers should be aseptic
procedures. After training, healthcare workers should be assessed for their
competence to carry out these types of procedures. [2003] [2003]
1.2.4.2 Intermittent self-catheterisation is a clean procedure. A lubricant for single-
patient use is required for non-lubricated catheters. [2003] [2003]
1.2.4.3 For urethral catheterisation, the meatus should be cleaned before insertion of
the catheter, in accordance with local guidelines/policy. [2003] [2003]
1.2.4.4 An appropriate lubricant from a single-use container should be used during
catheter insertion to minimise urethral trauma and infection. [2003] [2003]
1.2.5 1.2.5 Catheter maintenance Catheter maintenance
1.2.5.1 Indwelling catheters should be connected to a sterile closed urinary drainage
system or catheter valve. [2003] [2003]
1.2.5.2 Healthcare workers should ensure that the connection between the catheter
and the urinary drainage system is not broken except for good clinical reasons
(for example changing the bag in line with the manufacturer's
recommendations). [2003] [2003]
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1.2.5.3 Healthcare workers must decontaminate their hands and wear a new pair of
clean, non-sterile gloves before manipulating a patient's catheter, and must
decontaminate their hands after removing gloves. [2003] [2003]
1.2.5.4 Patients managing their own catheters, and their carers, must be educated
about the need for hand decontamination[16] before and after manipulation of
the catheter, in accordance with the recommendations in the standard
principles section (section 1.1). [2003, amended 2012] [2003, amended 2012]
1.2.5.5 Urine samples must be obtained from a sampling port using an aseptic
technique. [2003] [2003]
1.2.5.6 Urinary drainage bags should be positioned below the level of the bladder, and
should not be in contact with the floor. [2003] [2003]
1.2.5.7 A link system should be used to facilitate overnight drainage, to keep the
original system intact. [2003] [2003]
1.2.5.8 The urinary drainage bag should be emptied frequently enough to maintain
urine flow and prevent reflux, and should be changed when clinically indicated.
[2003] [2003]
1.2.5.9 The meatus should be washed daily with soap and water. [2003] [2003]
1.2.5.10 To minimise the risk of blockages, encrustations and catheter-associated
infections for patients with a long-term indwelling urinary catheter:
• develop a patient-specific care regimen
• consider approaches such as reviewing the frequency of planned catheter changes and
increasing fluid intake
• document catheter blockages. [new 2012] [new 2012]
1.2.5.11 Bladder instillations or washouts must not be used to prevent catheter-
associated infections. [2003] [2003]
1.2.5.12 Catheters should be changed only when clinically necessary or according to the
manufacturer's current recommendations. [2003] [2003]
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1.2.5.13 When changing catheters in patients with a long-term indwelling urinary
catheter:
• do not offer antibiotic prophylaxis routinely
• consider antibiotic prophylaxis[17] for patients who:
- have a history of symptomatic urinary tract infection after catheter change or or
- experience trauma[18] during catheterisation. [new 2012] [new 2012]
1.3 1.3 Enteral feeding Enteral feeding
1.3.1 1.3.1 Education of patients, their carers and healthcare workers Education of patients, their carers and healthcare workers
1.3.1.1 Patients and carers should be educated about and trained in the techniques of
hand decontamination, enteral feeding and the management of the
administration system before being discharged from hospital. [2003] [2003]
1.3.1.2 Healthcare workers should be trained in enteral feeding and management of the
administration system. [2003] [2003]
1.3.1.3 Follow-up training and ongoing support of patients and carers should be
available for the duration of home enteral tube feeding. [2003] [2003]
1.3.2 1.3.2 Preparation and storage of feeds Preparation and storage of feeds
1.3.2.1 Wherever possible pre-packaged, ready-to-use feeds should be used in
preference to feeds requiring decanting, reconstitution or dilution. [2003] [2003]
1.3.2.2 The system selected should require minimal handling to assemble, and be
compatible with the patient's enteral feeding tube. [2003] [2003]
1.3.2.3 Effective hand decontamination must be carried out before starting feed
preparation. [2003] [2003]
1.3.2.4 When decanting, reconstituting or diluting feeds, a clean working area should
be prepared and equipment dedicated for enteral feed use only should be used.
[2003] [2003]
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1.3.2.5 Feeds should be mixed using cooled boiled water or freshly opened sterile water
and a no-touch technique. [2003] [2003]
1.3.2.6 Feeds should be stored according to the manufacturer's instructions and, where
applicable, food hygiene legislation. [2003] [2003]
1.3.2.7 Where ready-to-use feeds are not available, feeds may be prepared in advance,
stored in a refrigerator, and used within 24 hours. [2003] [2003]
1.3.3 1.3.3 Administration of feeds Administration of feeds
1.3.3.1 Use minimal handling and an aseptic technique to connect the administration
system to the enteral feeding tube. [new 2012] [new 2012]
1.3.3.2 Ready-to-use feeds may be given for a whole administration session, up to a
maximum of 24 hours. Reconstituted feeds should be administered over a
maximum 4-hour period. [2003] [2003]
1.3.3.3 Administration sets and feed containers are for single use and must be
discarded after each feeding session. [2003] [2003]
1.3.4 1.3.4 Care of insertion site and enteral feeding tube Care of insertion site and enteral feeding tube
1.3.4.1 The stoma should be washed daily with water and dried thoroughly. [2003] [2003]
1.3.4.2 To prevent blockages, flush the enteral feeding tube before and after feeding or
administering medications using single-use syringes or single-patient-use
(reusable) syringes according to the manufacturer's instructions. Use:
• freshly drawn tap water for patients who are not immunosuppressed
• either cooled freshly boiled water or sterile water from a freshly opened container for
patients who are immunosuppressed. [new[new 2012] 2012]
1.4 1.4 Vascular access devices Vascular access devices
1.4.1 1.4.1 Education of patients, their carers and healthcare workers Education of patients, their carers and healthcare workers
1.4.1.1 Before discharge from hospital, patients and their carers should be taught any
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techniques they may need to use to prevent infection and safely manage a
vascular access device[19]. [2003, amended 2012] [2003, amended 2012]
1.4.1.2 Healthcare workers caring for a patient with a vascular access device[19] should
be trained, and assessed as competent, in using and consistently adhering to the
infection prevention practices described in this guideline. [2003, amended [2003, amended
2012] 2012]
1.4.1.3 Follow-up training and support should be available to patients with a vascular
access device[19] and their carers. [2003, amended 2012] [2003, amended 2012]
1.4.2 1.4.2 General asepsis General asepsis
1.4.2.1 Hands must be decontaminated (see section 1.1.2) before accessing or dressing
a vascular access device. [new 2012] [new 2012]
1.4.2.2 An aseptic technique[20] must be used for vascular access device catheter site
care and when accessing the system. [new 2012] [new 2012]
1.4.3 1.4.3 Vascular access device site care Vascular access device site care
1.4.3.1 Decontaminate the skin at the insertion site with chlorhexidine gluconate[21] in
70% alcohol before inserting a peripheral vascular access device or a
peripherally inserted central catheter. [new[new 2012] 2012]
1.4.3.2 Use a sterile transparent semipermeable membrane dressing to cover the
vascular access device insertion site. [new 2012] [new 2012]
1.4.3.3 Consider a sterile gauze dressing covered with a sterile transparent
semipermeable membrane dressing only if the patient has profuse perspiration,
or if the vascular access device insertion site is bleeding or oozing. If a gauze
dressing is used:
• change it every 24 hours, or sooner if it is soiled and and
• replace it with a sterile transparent semipermeable membrane dressing as soon as
possible. [new 2012] [new 2012]
1.4.3.4 Change the transparent semipermeable membrane dressing covering a central
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venous access device insertion site every 7 days, or sooner if the dressing is no
longer intact or moisture collects under it. [2012] [2012]
1.4.3.5 Leave the transparent semipermeable membrane dressing applied to a
peripheral cannula insertion site in situ for the life of the cannula, provided that
the integrity of the dressing is retained. [new 2012] [new 2012]
1.4.3.6 Dressings used on tunnelled or implanted central venous catheter sites should
be replaced every 7 days until the insertion site has healed, unless there is an
indication to change them sooner. [2003] [2003]
1.4.3.7 Healthcare workers should ensure that catheter-site care is compatible with
catheter materials (tubing, hubs, injection ports, luer connectors and
extensions) and carefully check compatibility with the manufacturer's
recommendations. [2003] [2003]
1.4.3.8 Decontaminate the central venous catheter insertion site and surrounding skin
during dressing changes using chlorhexidine gluconate[21] in 70% alcohol, and
allow to air dry. Consider using an aqueous solution of chlorhexidine gluconate
if the manufacturer's recommendations prohibit the use of alcohol with their
catheter. [2012] [2012]
1.4.3.9 Individual sachets of antiseptic solution or individual packages of antiseptic-
impregnated swabs or wipes should be used to disinfect the dressing site.
[2003] [2003]
1.4.4 1.4.4 General principles for management of vascular access General principles for management of vascular access devices devices
1.4.4.1 Decontaminate the injection port or vascular access device catheter hub before
and after accessing the system using chlorhexidine gluconate[21] in 70% alcohol.
Consider using an aqueous solution of chlorhexidine gluconate if the
manufacturer's recommendations prohibit the use of alcohol with their
catheter. [new 2012] [new 2012]
1.4.4.2 In-line filters should not be used routinely for infection prevention. [2003] [2003]
1.4.4.3 Antibiotic lock solutions should not be used routinely to prevent catheter-
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related bloodstream infections (CRBSI). [2003] [2003]
1.4.4.4 Systemic antimicrobial prophylaxis should not be used routinely to prevent
catheter colonisation or CRBSI, either before insertion or during the use of a
central venous catheter. [2003] [2003]
1.4.4.5 Preferably, a single lumen catheter should be used to administer parenteral
nutrition. If a multilumen catheter is used, one port must be exclusively
dedicated for total parenteral nutrition, and all lumens must be handled with the
same meticulous attention to aseptic technique. [2003] [2003]
1.4.4.6 Preferably, a sterile 0.9 percent sodium chloride injection should be used to
flush and lock catheter lumens. [2003] [2003]
1.4.4.7 When recommended by the manufacturer, implanted ports or opened-ended
catheter lumens should be flushed and locked with heparin sodium flush
solutions. [2003] [2003]
1.4.4.8 Systemic anticoagulants should not be used routinely to prevent CRBSI. [2003] [2003]
1.4.4.9 If needleless devices are used, the manufacturer's recommendations for
changing the needleless components should be followed. [2003] [2003]
1.4.4.10 When needleless devices are used, healthcare workers should ensure that all
components of the system are compatible and secured, to minimise leaks and
breaks in the system. [2003] [2003]
1.4.4.11 When needleless devices are used, the risk of contamination should be
minimised by decontaminating the access port with either alcohol or an
alcoholic solution of chlorhexidine gluconate[21] before and after using it to
access the system. [2003] [2003]
1.4.4.12 In general, administration sets in continuous use need not be replaced more
frequently than at 72-hour intervals unless they become disconnected or a
catheter-related infection is suspected or documented. [2003] [2003]
1.4.4.13 Administration sets for blood and blood components should be changed every
12 hours, or according to the manufacturer's recommendations. [2003] [2003]
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1.4.4.14 Administration sets used for total parenteral nutrition infusions should
generally be changed every 24 hours. If the solution contains only glucose and
amino acids, administration sets in continuous use do not need to be replaced
more frequently than every 72 hours. [2003] [2003]
1.4.4.15 Avoid the use of multidose vials, in order to prevent the contamination of
infusates. [new 2012] [new 2012]
[7] In accordance with current health and safety legislation (at the time of publication of the
guideline [March 2012]): Health and Safety at Work Act 1974, Management of Health and Safety
at Work Regulations 1999, Health and Safety Regulations 2002, Control of Substances Hazardous
to Health Regulations 2002, Personal Protective Equipment Regulations 2002 and Health and
Social Care Act 2008.
[8] BS EN 1500:2013.
[9] For the purposes of this guideline, the GDG considered bare below the elbow to mean: not
wearing false nails or nail polish; not wearing a wrist-watch or stoned rings; wearing short-sleeved
garments or being able to roll or push up sleeves.
[10] At the time of publication of the guideline (March 2012): BS EN 455 Parts 1–4 Medical gloves for
single use.
[11] For guidance see Management and disposal of healthcare waste (HTM 07-01).
[12] The updated recommendation contains 'should' rather than 'must' (which is in the 2003
guideline) because the GDG considered that this is not covered by legislation (in accordance with
the NICE guidelines manual, 2009).
[13] It is acceptable to bend needles when they are part of an approved sharps safety device.
[14] See www.legislation.gov.uk/uksi/2013/645/contents/made.
[15] See BS EN ISO 23907:2012.
[16] The text 'Patients managing their own catheters, and their carers, must be educated about the
need for hand decontamination…' has replaced 'Carers and patients managing their own catheters
must wash their hands…' in the 2003 guideline.
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[17] At the time of publication of the guideline (March 2012), no antibiotics have a UK marketing
authorisation for this indication. Informed consent should be obtained and documented.
[18] The GDG defined trauma as frank haematuria after catheterisation or two or more attempts of
catheterisation.
[19] The updated recommendation contains 'vascular access device' rather than 'central venous
catheter'. This change has been made because peripherally inserted catheters were included in the
scope of the guideline update.
[20] The GDG considered that Aseptic Non Touch Technique (ANTT™) is an example of an aseptic
technique for vascular access device maintenance, which is widely used in acute and community
settings and represents a possible framework for establishing standardised guidance on aseptic
technique.
[21] In 2012 a safety alert for chlorhexidine was issued related to the risk of adverse events.
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2 2 Research recommendations Research recommendations The Guideline Development Group has made the following recommendations for research, based
on its review of evidence, to improve NICE guidance and patient care in the future.
2.1 2.1 Standard principles of infection prevention and Standard principles of infection prevention and control control
What are the barriers to compliance with the standard principles of infection prevention and
control that patients and carers experience in their own homes?
Why this is important Why this is important
Recent changes to the delivery of healthcare mean that care is increasingly delivered within a
patient's home environment. Infection prevention in this setting is just as important as in hospital.
There are currently approximately 6 million unpaid carers in the UK, a number that is likely to
increase with an aging population. The association between carer training and infection rates is
unknown. No evidence of surveillance of healthcare-associated infections in the community is
currently available in the UK.
A qualitative study is needed to investigate the themes surrounding the barriers to patient and
carer compliance with the standard principles of infection prevention in their own homes. It would
be important to assess whether lack of awareness or knowledge is a barrier. If patients and carers
have received education, this should be assessed to see if this was applicable to the patient's home
setting. Areas of low compliance in the home environment need to be identified. The findings could
have far-reaching implications for discharge planning and duty of care.
2.2 2.2 Hand decontamination Hand decontamination
When clean running water is not available, what is the clinical and cost effectiveness of using wipes,
gels, handrubs or other products to remove visible contamination?
Why this is important Why this is important
Community healthcare workers often encounter challenges in carrying out hand decontamination
when there is no access to running water. This particularly affects ambulance service staff, who
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often provide emergency care at locations where running water is not available. No evidence from
randomised controlled trials is available on the most effective way for community-based
healthcare workers to remove physical contamination, such as blood, from their hands in the
absence of running water. In recent years, hand decontamination products that can be used
without running water, such as gels, handrubs and wipes, have become available. However, their
efficacy and suitability in actual clinical practice for use with visibly dirty hands has not been
determined. A randomised controlled trial is required to compare hand wipes (alcohol and
antiseptic), hand gels and other hand decontamination products that can be used without running
water, to determine the most effective way to remove physical dirt in the absence of running water,
in order to make a recommendation for their use in real situations. The primary outcome measure
should be colony-forming units on the basis of the adenosine triphosphate (ATP) surface test.
2.3 2.3 Intermittent urinary catheters: catheter selection Intermittent urinary catheters: catheter selection
For patients performing intermittent self-catheterisation over the long term, what is the clinical
and cost effectiveness of single-use non-coated versus single-use hydrophilic versus single-use gel
reservoir versus reusable non-coated catheters with regard to the following outcomes:
symptomatic urinary tract infections, urinary tract infection-associated bacteraemia, mortality,
patient comfort and preference, quality of life, and clinical symptoms of urethral damage?
Why this is important Why this is important
Long-term (more than 28 days) intermittent self-catheterisation is performed by many people
living in the community. It is important that the choice between intermittent catheters is informed
by robust evidence on clinical and cost effectiveness.
The cost-effectiveness model developed for this guideline combined evidence of clinical
effectiveness, costs and quality of life with respect to symptomatic urinary tract infection and
associated complications. The results of the analysis showed that reusable non-coated catheters
were the most cost-effective option for intermittent self-catheterisation. However, the clinical
evidence informing this model was of low to very low quality. Currently, non-coated catheters are
considered to be single-use devices. In order to make an 'off-licence' recommendation for the use of
these catheters, better quality evidence is needed.
A four-arm randomised controlled trial is required. The trial population should be diverse, including
wheelchair users, people with spinal cord injuries and people over 16 who regularly self-
catheterise. The primary outcome measures should be incidence of symptomatic urinary tract
infections, urinary tract infection-associated bacteraemia, mortality, patient comfort and
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preference, quality of life, clinical symptoms of urethral damage, and costs.
2.4 2.4 Indwelling urinary catheters: catheter selection Indwelling urinary catheters: catheter selection
For patients using a long-term indwelling urinary catheter, what is the clinical and cost
effectiveness of impregnated versus hydrophilic versus silicone catheters in reducing symptomatic
urinary tract infections, encrustations and/or blockages?
Why this is important Why this is important
Long-term indwelling catheters (both urethral and suprapubic) are commonly used in both hospital
and community care settings. Long-term catheterisation carries a significant risk of symptomatic
urinary tract infection, which can lead to more serious complications. Several different types of
impregnated and hydrophilic long-term indwelling catheters on the market claim to be more
effective than non-coated catheters, but are also more expensive.
The clinical evidence review for the guideline revealed an absence of evidence for the effectiveness
of indwelling catheters over the long term. A comparison of impregnated (for example, with silver),
hydrophilic and silicone catheters is needed. The primary outcome measures should be
symptomatic urinary tract infections, encrustations, blockages, cost/resource use and quality of
life. Secondary outcome measures should include the mean number of days the catheter remains in
situ (mean dwell time) and patient comfort.
2.5 2.5 Indwelling urinary catheters: antibiotic prophylaxis Indwelling urinary catheters: antibiotic prophylaxis
When recatheterising patients who have a long-term indwelling urinary catheter, what is the
clinical and cost effectiveness of single-dose antibiotic prophylaxis in reducing symptomatic
urinary tract infections in patients with a history of urinary tract infections associated with
catheter change?
Why this is important Why this is important
The immediate clinical and economic impact of urinary tract infection is so great that patients at
risk of infection are sometimes offered the option to receive prophylactic antibiotics. However, the
widespread use of antibiotics, including their prophylactic use, has been identified as a major factor
in the increasing levels of antibiotic resistance observed across England and Wales. There is
currently an absence of evidence about the short-term and long-term effects of prophylactic
antibiotic use during catheter change. The GDG identified this as an important area for research to
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establish the benefits and harms of this practice in order to develop future guidance (the
recommendation on this topic in the current guideline was based on GDG consensus).
A randomised controlled trial or cohort trial comparing single-dose antibiotic prophylaxis with
selected major antibiotic groups is needed. The primary outcome measures should be symptomatic
urinary tract infection, cost and quality of life. This is an important area for patients as it could
minimise the inappropriate use of antibiotics
2.6 2.6 Vascular access devices: skin decontamination Vascular access devices: skin decontamination
What is the clinical and cost effectiveness of 2% chlorhexidine in alcohol versus 0.5% chlorhexidine
in alcohol versus 2% chlorhexidine aqueous solution versus 0.5% chlorhexidine aqueous solution
for cleansing skin (before insertion of peripheral vascular access devices [VADs] and during
dressing changes of all VADs) in reducing VAD-related bacteraemia and VAD site infections?
Why this is important Why this is important
The effective management of VADs is important for reducing phlebitis and bacteraemia. In the
community, compliance is improved when a single solution is used for all aspects of VAD-related
skin care. There is no direct evidence comparing different percentages of chlorhexidine in aqueous
and alcohol solutions, and little evidence on the use of such solutions in the community. A
randomised controlled trial is required to compare the clinical and cost effectiveness of the
different solutions available. The trial should enrol patients in the community with a VAD. The
protocol would need to use the same skin preparation technique regardless of solution, and could
also investigate the effects of decontamination technique and drying time. The primary outcome
measures should be rate of VAD-related bacteraemia, rate of VAD site infections, mortality, cost
and quality of life. Secondary outcome measures should include visual infusion phlebitis (VIP)
score, insertion times and skin irritation.
More information More information
You can also see this guideline in the NICE pathways on prevention and control of healthcare
associated infections and urinary incontinence in neurological disease.
To find out what NICE has said on topics related to this guideline, see our web page on
healthcare-associated infections.
See also the guideline committee's discussion and the evidence reviews (in the full guideline),
and information about how the guideline was developed, including details of the committee.
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Update information Update information February 2017: February 2017: A footnote was added to recommendation 1.1.4.2 linking to Health and Safety
(Sharp Instruments in Healthcare) Regulations 2013. A footnote linking to a safety alert on
chlorhexidine was added to recommendations 1.4.3.1, 1.4.3.8, 1.4.4.1 and 1.4.4.11. Other footnotes
were updated with references to revised or replaced British Standards and other regulations.
August 2013: August 2013: A clarification has been made to recommendation 1.1.4.2 on the disposal of used
standard needles.
This guidance is a partial update of NICE clinical guideline 2 (published June 2003) and replaces
it.
Recommendations are marked as [2003][2003], [2003, amended 2012][2003, amended 2012], [2012][2012] or [new 2012][new 2012]:
• [2003][2003] indicates that the evidence has not been updated and reviewed since 2003
• [2003, amended 2012][2003, amended 2012] indicates that the evidence has not been updated and reviewed since
2003, but a small amendment has been made to the recommendation
• [2012][2012] indicates that the evidence has been reviewed but no changes have been made to the
recommendation
• [new 2012][new 2012] indicates that the evidence has been reviewed and the recommendation has
been updated or added.
ISBN: 978-1-4731-2367-0
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Accreditation Accreditation
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Recommended